power of attorney on _________________________, of
_________________________,

as the true and lawful attorney for me and in my
name, place and stead, and for my use and benefit regarding:
________________________________________________________.

Said attorney-in-fact shall not be limited or
restricted by the foregoing specifications of the situation.The rights, powers and authority of said
attorney-in-fact granted in this instrument shall commence and be in full force
and effect on _____________ (month & day) ______ (year) and such rights,
powers and authority shall remain in full force and effect thereafter until I,
_____________, give notice in writing that such power is terminated.This Power of Attorney conferred upon the
aforementioned shall not be affected by any subsequent disability or incapacity
that may befall me.

FURTHERMORE, upon a finding of incompetence by a
court of appropriate jurisdiction, this Power of Attorney shall be irrevocable
until such time as said court determines that I am no longer incompetent.

____________________________________

Signature

I, _______________________, whose name is signed to
the foregoing instrument, having been duly qualified according to the law, do
hereby acknowledge that I signed and executed this Power of Attorney; that I am
of sound mind; that I am eighteen (18) years of age or older; that I signed it
willingly and am under no constraint or undue influence; and that I signed it
as my free and voluntary act for the purpose therein expressed.